Health policy and planning最新文献

The Republic of Chad has one of the highest rates of maternal mortality in the world. With scarce resources to respond to competing demands, pragmatic evidence-based planning tools are needed to aid planning and support priority setting. This action research aimed to develop a tool to support maternal health (MH) planning and prioritization decisions and identify priority regions/provinces for intervention in Chad based on aggregate MH coverage gap scores (Target-Coverage=Coverage Gap). A rapid review was conducted to identify key indicators and relevant national targets. The 2019 Multiple Indicator Cluster Survey and other national surveys were the data sources for selected indicators at the provincial level. Aggregate MH coverage gaps were calculated and displayed using Geographic Information System software to visualize variations by province. Eleven key informant interviews (KIIs) and six focus group discussions (FGDs) were conducted with clinicians and administrators to understand existing MH planning, prioritization, and maternal mortality risks in Chad. Wide provincial variation in aggregate MH coverage gaps was identified (mean score 374.3, SD: 77.4). Indicators contributing the most to coverage gaps include emergency obstetric care, adolescent births, tetanus vaccination, and delivery by skilled health personnel. Two weighting scenarios for the coverage gap scores are also considered. KIIs and FGDs revealed that existing MH planning in Chad differs provincially and by health system level, with no clear prioritization processes identified. Main themes regarding MH risks reported by stakeholders included challenges relating to the health system, policy landscape, country and population-specific factors, along with specific MH threats. Current centralized planning approaches may benefit from greater consideration of provincial differences to support more efficient and equitable resource distribution. This multi-indicator assessment offers an adaptable approach for evidence-based MH resource allocation to prioritize sub-national areas with worst health indicators in resource-limited settings, although further research is needed to test its impact.

Menstrual hygiene management among girls in rural India poses a substantial challenge for public health, education, and quality of life, exacerbated by limited access and affordability of menstrual products. In response to these issues, the Government of India initiated the Menstrual Hygiene Scheme (MHS) to enhance access and awareness. This study evaluates the impact of the MHS in Assam and Tripura designated" treatment states" with consistent pad supply from 2017 to 2021 compared to neighboring" control states" with negligible pad distribution. Utilizing data from two National Family Health Surveys, NFHS-4 & NFHS-5, and employing propensity score matching difference-in-differences approach, we isolated the causal effect of the MHS distribution program. The key findings reveal a significant rise in sanitary pad and hygienic method usage in the treatment states, particularly among girls aged 15-19 who received pads during the survey period. Their sanitary pad usage increased by 10.6 percentage points [95 % Confidence Interval (CI) (0.046,0.167)], and adoption of hygienic methods overall saw a 13.8 percentage points [95 % CI (0.087,0.188)] jump. Notably, younger girls aged 15-19 also experienced a 6.1 percentage point [95 CI (0.004,0.118)] increase in their understanding of ovulation, showcasing the MHS's potential to go beyond providing products and promoting menstrual health awareness. A rise in reported sexually transmitted infections in both age groups, with a statistically significant 1.8 percentage point [95 % CI (0.004,0.032)] increase for younger girls, warrants further exploration. Disparities in impact were observed, with girls with high media exposure and greater autonomy demonstrating greater improvements in hygienic practices, highlighting the importance of information dissemination and empowering girls. Most socioeconomic groups, except the highest wealth and education levels, witnessed rises in hygienic method usage, indicating the scheme's potential to reduce inequalities while hinting at the need for tailored interventions for marginalized communities.

Delphi studies are rapidly gaining prominence in global health research. However, researchers' modifications to the Delphi method are often not well-described or justified, limiting opportunities to systematically learn from these studies when the methods are applied to other topics and settings. This paper aims to describe an approach to implementing a modified Delphi study and reflect on the research process in the context of a multi-country study of implementation science research priorities to advance Universal Health Coverage (UHC). We review trends in the use of the modified Delphi method in global health research, outline our three-phased modified Delphi approach, and share reflections on five decision points for implementing the study: 1) identifying and recruiting participants for the expert panel, 2) addressing participant attrition between rounds, 3) justifying the most appropriate cutoff points, 4) incorporating new items raised by participants in open-ended survey sections, and 5) ensuring maximum variation in perspective in the panel of experts. Insights from this work foster greater understanding of the underlying assumptions for, and interpretation of, 'modified' in modified Delphi studies. This study will encourage critical dialogue about points of methodological contention in Delphi methodology and thus, are relevant for scaling the use of modified Delphi studies in public health, including global health research.

Disasters are complex global problems with increasing impact with rising prevalence of associated illness, mortality, and intensifying health inequities. In recent years, there has been an emphasis on integrating trauma-informed care approaches into health policies and protocols. The purpose of the current study was to investigate the benefits of a trauma-informed healthcare training program for hospital-based healthcare providers with a focus on knowledge acquisition, empowerment of professional practice, and personal well-being. The program was implemented in the aftermath of the 2023 earthquakes in southeastern Türkiye. The training consisted of four modules, developed based on psychological trauma theories, behavior change theories, and was evaluated using a mixed methods approach. Assessments were conducted at the end of training program, at baseline, and at six-months follow-up. A structured questionnaire including items covering the content of the training, trainer effectiveness, and program suitability, was administered at the end of training program. At six months, participants completed an 18-item follow-up questionnaire which assessed their understanding of the principles of the trauma-informed care approach. The Maslach Burnout Inventory was also administered, and themes regarding the impact of the training program extracted through in-depth individual qualitative interviews. Data were obtained from 501program participant. The intervention program was found to improve healthcare workers' understanding of trauma, professional practices, and interpersonal relationships, and significantly reduced symptoms of burnout. These results demonstrate the critical role of trauma-informed training programs in hospitals in disaster affected regions, especially when assistance to survivors will be enhanced by strengthening healthcare workers' resilience and improving their perceptions of service efficacy and value. The study highlights the need for more widespread adoption of these training initiatives and emphasizes that they may play significant future roles in transforming trauma-informed healthcare systems in disaster-prone countries and regions.

The pro-rich nature of catastrophic health expenditure (CHE) indicators has garnered criticism, inspiring the exploration of the subjective approach as a complementary method. However, no studies have examined the discrepancy between subjective and objective approaches. Employing data from the Chinese Social Survey (CSS) 2013-2021 waves, we analysed the discrepancy between objective and subjective CHE and its associated socioeconomic factors using logit regression modelling. Overall, self-rating generated higher CHE incidence (28.35% to 33.72%) compared to objective indicators (9.92% to 21.97%). Objective indicators did not support 17.57% to 23.90% of self-rated cases of household CHE, while 2.73% to 8.42% of households classified with CHE by objective indicators did not self-rate with CHE. The normative subsistence spending indicator showed the least consistency with self-rating (70.66% to 74.28%), while the budget share method produced the most consistent estimation (72.73% to 76.10%). Living with elderly and young children (AOR: 1.069 to 1.169, p<0.1), lower educational attainment (AOR: 1.106 to 1.225, P<0.1), lower income (AOR: 1.394 to 2.062, P<0.01), and lower perceived social class (AOR: 1.537 to 2.801, P<0.05) were associated with higher odds of self-rated CHE without support from objective indicators. Conversely, low socioeconomic status (AOR: 0.324 to 0.819, P<0.1) was associated with lower odds of missing CHE cases classified by objective indicators in self-rating. The commonly used objective indicators for assessing CHE may attract doubts about their fairness from socioeconomically disadvantaged people. The CHE subjective approach can be adopted as a complementary measure to monitor financial risk protection.

In low-and-middle income countries, maternal mental health needs remain neglected, and common mental disorders during pregnancy and after birth are routinely associated with hormonal changes. The psycho-social, and spiritual components of childbirth are often downplayed. A qualitative study was conducted as part of a wider realist evaluation on health systems responsiveness to examine the interrelationships between pregnant and postnatal women, their families, and their environment, and how these influence women's interactions with healthcare providers in Ghana. Data collection methods combined six qualitative interviews (n= 6) and 18 focus group discussions (n= 121) with pregnant and postnatal women, their relatives and health care providers (midwives, community mental health nurses) at the primary healthcare level. Data analysis was based on the Context-Mechanism-Outcome heuristic of realist evaluation methodology. A programme theory was developed and iteratively refined, drawing on Crowther's ecology of birth theory to unpack how context shapes women's interactions with public and alternative health care providers. We found that context interacts dynamically with embodiment, relationality, temporality, spatiality, and mystery of childbirth experiences, which in turn influence women's wellbeing in three primary areas. There is an intricate intersection of pregnancy with mental health impacting women's expectations of temporality, which does not always coincide with the timings provided by formal healthcare services. Societal deficiencies in social support structures for women facing economic challenges become particularly evident during the pregnancy and postnatal period, where women need heightened assistance. Socio-cultural beliefs associated with the mystery of childbirth, support the role of private providers in offering women a feeling of protection from uncertainty. Co-production of context specific interventions, including the integration of maternal and mental health policies, with relevant stakeholders can help formal healthcare providers accommodate women's perspectives on spirituality and mental health, which can subsequently help to make health system responsive to maternal mental health conditions.

The emergence of 'resilience' as a concept for analysing health systems - especially in low- and middle-income countries - has been trailed by debates on whether 'resilience' is a process or an outcome. This debate poses a methodological challenge. What 'health system resilience' is interpreted to mean shapes the approach taken to its analysis. To address this methodological challenge, we propose 'learning' as a concept versatile enough to navigate the 'process versus outcome' tension. Learning - defined as "the development of insights, knowledge, and associations between past actions, the effectiveness of those actions, and future actions" - we argue, can animate features that tend to be silenced in analyses of resilience. As with learning, the processes involved in resilience are cyclical: from absorption to adaptation, to transformation, and then to anticipation of future disruption. Learning illuminates how resilience occurs - or fails to occur - interactively and iteratively within complex systems while acknowledging the contextual, cognitive, and behavioural capabilities of individuals, teams and organizations that contribute to a system's emergence from or evolution given shocks/stress. Learning analysis can help to resist the pull towards framing resilience as an outcome - as resilience is commonly used to mean or suggest a state or an attribute, rather than a process that unfolds, whether the outcomes are deemed positive or not. Analysing resilience as a learning process can help health systems researchers better systematically make sense of health system responses to present and future stress/shocks. In qualitative or quantitative analyses, seeing what is to be analysed as 'learning' rather than the more nebulous 'resilience' can refocus attention in relation to what is to be measured, explained, and how - premised on the understanding that a health system with the ability to learn is one with the ability to be resilient, regardless of the outcome of such a process.

In Indonesia, primary health centres (PHCs) are mandated to provide essential medicines to ensure equal access to medication for all Indonesians, as stated in the national medicine policy. However, limited information is available regarding the actual practices of health workers within the context of decentralised governance. This paper investigates the discrepancies between national policies and local practices in two Indonesian districts, shedding light on coping mechanisms employed in each phase of medicine management within PHCs. The mixed-method study began by identifying pertinent policies addressing medicine management in PHCs. Subsequently, panel data on patient visits to tuberculosis, maternal and neonatal health (MNH) and non-communicable disease (NCD) services were collected from 2019 to 2022. After analysing the panel data, interviews were conducted with 56 health workers including physicians, nurses, pharmacists, midwives, and public health programme managers regarding their views on fluctuations in medicine stocks and the patient visits data. These participants included pharmacists and programme managers specialising in tuberculosis, MNH, and NCD care and were affiliated with PHCs and district health offices (DHO). Our findings highlight the occasional unavailability of essential medicines in PHCs, with stockouts being attributed to supplier shortages at provincial and national levels and to variations in the capacity of the local health system. Low-skilled pharmaceutical staff are a contributing factor in each phase of medicine management. Additionally, health workers employ coping mechanisms, such as deviating from policy on the use of capitation funds to purchase medicines, to manage temporary stockouts. To tackle systemic stockouts, central government should prioritise capacity-building among health workers, by establishing a continuous and easily accessible local learning system.

There is a widely held view that good management improves organisational performance. However, hospitals are complex organisations and the relationship between management practices and health service delivery is not straightforward. We conducted a global, systematic literature review of the quantitative evidence on the link between the adoption of management practices and quality of care in hospitals. We searched in PubMed, EMBASE, EconLit, Global Health and Web of Science on 16th October 2024, without language or country restrictions. We included empirical studies from January 1, 2000, onward, examining the quantitative association between hospital management practices and quality of care. Outcomes included structural quality (availability of resources such as drugs and equipment), clinical quality (adherence to guidelines), health outcomes and patient satisfaction or experience with care. In every study, each tested association was categorised as significantly positive (at the 5 percent level), null or significantly negative. The study was registered with PROSPERO (CRD42022301462). Of 11,731 articles, 25 studies met the inclusion criteria and had acceptable risk of bias. Studies were equally distributed between high-income and low- and middle-income countries, with 22 cross-sectional and three intervention studies. Of 111 associations, 55 (49.5%) were significantly positive, 1 (1%) was significantly negative, and 55 (49.5%) were null. Among associations tested, the majority were significantly positive for structural quality (79%), clinical quality (60%) and health outcomes (57%), while most associations between hospital management and patient satisfaction (80%) were null. The findings are mixed, with a similar proportion of positive and null associations between management practices and quality of care across studies. The evidence is limited by risk of bias introduced by non-randomised study designs. Evidence of positive associations in some settings warrants further investigation of the association through intervention studies or natural experiments. This could leverage methodological developments in quantitatively measuring management, highlighted by this review.

Sustainable and equitably contributed domestic health financing is essential for improving health and making progress towards Universal Health Coverage (UHC) in Low- and Middle-Income Countries. In this study, we explore the pathways through which development partners influence the mix of domestic health financing sources in Senegal. We performed a qualitative case study comprised of 32 key stakeholder interviews and a purposive document review, supplemented by descriptive statistical analysis of World Health Organization and Organization for Economic Cooperation and Development data on health financing sources in Senegal. We developed a novel framework to analyse the different mechanisms and directions of development partner influence on domestic health financing contributions. We identified development partner influence via four mechanisms: setting aims and standards, lobbying/negotiation, providing policy/technical advice, and providing external financing. Overall, development partners worked to increase tax-based government contributions and expand Community-Based Health Insurance (CBHI), which is seemingly equity enhancing. Fungibility and intrinsic equity issues related to CBHI may however limit equity gains. We encourage stakeholders in the health financing sphere to use our framework and analysis to unpack how development partners affect domestic health financing in other settings. This could help identify dynamics that do not optimally enhance equity and support progress towards UHC, to help achieve more coherent policy-making across all domains of development partner activities in support of UHC. Future research should investigate the role of international creditors, lending and loan conditionalities on domestic health financing in recipient countries, including equity implications.